ADHD service use patterns in youth

Social gradient in use of health services and health-related quality of life of children with attention-deficit/hyperactivity disorder: A systematic review

Aims

ADHD (attention-deficit/hyperactivity disorder) affects 5% of children on average. Despite the high need to access services for ADHD treatment, not all children with ADHD utilise healthcare services equally. This study aims to systematically synthesise evidence of equity and equality in health service use/costs and health-related quality of life (HRQoL)/wellbeing of children with ADHD across socioeconomic (SES) classes.

Methods

The literature search was conducted across seven databases (Academic Search complete, MEDLINE Complete, PsycINFO, ERIC, Global Health, CINAHL and EconLit). The search was limited to peer-reviewed articles published to 23rd January 2023 in English and focused on children. Study quality was assessed using the Critical Appraisal Skills Program (CASP), Joanna Briggs Institute (JBI) and Mixed Methods Appraisal Tool (MMAT) checklists.

Results

25 out of 1207 articles were eligible for inclusion. The results showed that SES was associated with different types of healthcare utilisation. Only three studies were found on HRQoL/well-being. Children with ADHD from low SES families had lower HRQoL than children from high SES families.

Conclusion

This study found that a social gradient exists in both healthcare service use and children's HRQoL among those with ADHD.

Patterns and Predictors of Service Utilization Among Youth With ADHD-Predominantly Inattentive Presentation

Objective: This study examined rates and predictors of educational and mental health service utilization among youth with ADHD-predominantly inattentive presentation (ADHD-I). Method: Participants were 199 children with ADHD-I in Grades 2 to 5. Parents reported past-year child service utilization. Parents and teachers rated child ADHD and oppositional defiant disorder (ODD) symptom severity and functional impairment. Children completed an academic achievement test. Results: All children had impairment at school and home. Most received some sort of school service (79%), but only 23% received community-based services. ADHD symptom severity was unrelated to service utilization. However, higher parent-rated functional impairment predicted community service utilization. Academic underachievement and higher teacher-rated functional impairment predicted school service utilization. Conclusion: Many youth with ADHD-I experience impairment across domains without receiving adequate services for these problems. Functional impairment appears to be a stronger predictor of service utilization than ADHD symptom severity, demonstrating the importance of impairment in understanding service needs for ADHD-I.

Parent-reported symptoms, impairment, helpfulness of treatment, and unmet service needs in a follow-up of outpatient children with attention-deficit/hyperactivity disorder

BACKGROUND

Limited information exists regarding the associations between impairment, symptoms, helpfulness of treatments, and service needs after initial treatment of children with attention-deficit/hyperactivity disorder (ADHD).

AIMS

The aims of this study were to examine persistence rates and associations between parent-reported symptoms, impairment, helpfulness of treatments, and service needs in a retrospective follow-up study of children with ADHD.

METHODS

Parents of 214 children with a mean age of 12.6 years (SD = 2.1) who were diagnosed with ADHD at five child and adolescent mental health clinics (CAMHS) completed questionnaires 1-10 years (mean = 3.7 years, SD = 2.2) after baseline assessment. The response rate was 43.4%. A community comparison group (n = 110) was recruited from the same area.

RESULTS

Approximately two-thirds (60.3%) of the sample fulfilled the DSM-IV symptom criteria of ADHD at follow-up, 84.3% were functionally impaired, and most children (84.7%) were on medication. Inattentive and emotional symptoms were the strongest predictors of impairment across impairment areas. Perceived helpfulness of different treatments varied from 71.8-88.7%, and no significant difference was found between the ADHD sub-groups regarding reported helpfulness. 'Adjustment of the school situation' was the most frequent service need, and approximately half of the parents reported needs for care co-ordination. Children fulfilling the symptom criteria of the ADHD Combined sub-group were most impaired and had most service needs.

CONCLUSIONS

At follow-up, children were highly symptomatic and impaired, despite a high rate of persistent medication treatment. The findings underline the need for more tailored treatment and co-ordinated care over time.

A discrete choice conjoint experiment to evaluate parent preferences for treatment of young, medication naive children with ADHD

The current study examined treatment preferences of 183 parents of young (average age = 5.8 years, SD = 0.6), medication naive children with ADHD. Preferences were evaluated using a discrete choice experiment in which parents made choices between different combinations of treatment characteristics, outcomes, and costs. Latent class analysis yielded two segments of parents: (a) medication avoidant parents constituted 70.5% of the sample whose treatment decisions were strongly influenced by a desire to avoid medication, and (b) outcome oriented parents constituted 29.5% of the sample whose treatment decisions were most influenced by a desire for positive treatment outcomes. Parents in the outcome oriented segment were more stressed and depressed, had lower socioeconomic status and education, were more likely to be single parents, and had more disruptive and impaired children. Simulations predicted that parents would prefer treatments with behavior therapy over treatments with stimulant medication only.

Using freelisting to understand shared decision making in ADHD: parents' and pediatricians' perspectives

OBJECTIVE

To compare and contrast notions of ADHD among pediatricians and parents of affected children to understand the perspectives they bring to shared decision making (SDM).

METHODS

In this freelisting study, 60 parents of children with ADHD and 30 primary care pediatricians listed words reflecting their understanding of (1) Attention Deficit Hyperactivity Disorder (ADHD), (2) getting/offering help for ADHD, (3) talking to doctors/families about ADHD, and (4) "mental health." Smith's salience score established terms that were salient and cultural consensus analysis identified variation within subgroups of participants.

RESULTS

Parents' terms reflected ADHD's effects on the child and family, while clinicians often mentioned school. Lists suggested differing needs and goals for clinicians and subgroups of parents in SDM: "time" for clinicians, "learning" and "understanding" for non-college educated parents, and "comfort" and "relief" for college educated parents. Neither parents nor clinicians framed ADHD in the same way as "mental health."

CONCLUSION

Parents and clinicians, who conceptualize ADHD differently, should negotiate a shared understanding of ADHD as a basis for SDM. Treatment discussions should be tailored to encompass families' varied emotional and educational needs.

PRACTICE IMPLICATIONS

Fostering SDM in primary care is consonant with notions of ADHD as distinct from mental health.

Attention-deficit hyperactive disorder in school-aged children in Saudi Arabia

The current study was designed to explore the prevalence of attention-deficit hyperactive disorder (ADHD) in primary schools in Saudi Arabia. The study collected data from both teachers and parents for 708 primary school pupils attending grades 1-3 (7-9 years old), using DSM-IV criteria of ADHD. The result showed that the overall rate of ADHD was 2.7%, and in particular, the rate of attention types, 2.0%; hyperactive/impulsivity type, 1.4% and combined type, 0.7%. Teachers reported ADHD in a higher frequency than parents. However, applying a combination of reports from teachers and parents, screening of ADHD is likely to be more accurate. These findings highlight the importance of detecting ADHD in pupils at an early age and to develop a specific set of psychological clinical interventions for helping them.

Partnership in the Treatment of Childhood Mental Health Problems: A Pediatric Perspective

Pediatricians understand their role as promoting both the physical and mental health of children from birth until adulthood. Within the context of this long-term relationship, parents approach clinicians to address a full range of behavioral concerns ranging from variations of normal development to major mental illness. In this commentary that builds upon the earlier manuscripts in this collection, we explore the pediatrician's role in mental health care through the example of attention-deficit hyperactivity disorder (ADHD). ADHD is an ideal prototype for the exploration of partnership in mental health care because ADHD is the most common neurobehavioral disorder in childhood, it is commonly treated in primary care settings, multiple evidence-based treatments exist, personal values strongly influence the acceptability of treatment, treatment adherence is often poor, and effective treatment relies on the collaboration of pediatricians with families, schools, and the mental health system. Through the use of the Chronic Care Model for Child Health that emphasizes the importance of optimizing and coordinating systems of care for effective partnership, the following manuscript reviews the challenges and opportunities for pediatricians partnering with families and schools to address mental health problems. Strategies highlighted in the preceding papers are discussed within the context of this model.

Beyond polemics: science and ethics of ADHD

What is attention-deficit hyperactivity disorder (ADHD)? Why are so many children being diagnosed with ADHD and prescribed medication? Are stimulant drugs an effective and safe treatment strategy? This article explores the current state of scientific research into ADHD and the key social and ethical concerns that are emerging from the sharp rise in the number of diagnoses and the use of stimulant drug treatments in children. Collaborations among scientists, social scientists and ethicists are likely to be the most promising route to understanding what ADHD is and what stimulant drugs do.

Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder

Pelham, Wheeler, and Chronis (1998) reviewed the treatment literature on attention-deficit/hyperactivity disorder (ADHD) and concluded behavioral parent training (BPT) and behavioral classroom management (BCM) were well-established treatments for children with ADHD. This review updates and extends the finding of the prior review. Studies conducted since the 1998 review were identified and coded based on standard criteria, and effect sizes were calculated where appropriate. The review reinforces the conclusions of Pelham, Wheeler, and Chronis regarding BPT and BCM. Further, the review shows that intensive peer-focused behavioral interventions implemented in recreational settings (e.g., summer programs) are also well-established. The results of this update are discussed in the context of the existing treatment literature on ADHD. Implications for practice guidelines are suggested, as are directions for future research.